Psychiatry Research 297 (2021) 113730

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Traditional school bullying and cyberbullying: Prevalence, the effect on

mental health problems and self-harm behavior
Murat Eyuboglu a, *, Damla Eyuboglu a, Seval Caliskan Pala b, Didem Oktar b, Zeynep Demirtas b,
Didem Arslantas b, Alaettin Unsal b
a
Eskisehir Osmangazi University Faculty of Medicine, Department of Child and Adolescent Psychiatry, Eskisehir, Turkey
b
Eskisehir Osmangazi University Faculty of Medicine, Department of Public Health, Eskisehir, Turkey

A R T I C L E I N F O A B S T R A C T

Keywords: Bullying is widely recognized as a major psychosocial problem with substantial negative consequences. The
Bullying current study aimed to estimate the prevalence of traditional school bullying and cyberbullying and reciprocal
Cyberbullying associations between bullying involvement and mental health problems. The sample of the study consisted of
Victimization
6202 middle and high school students (age 11-18, M= 14.4 ±1.9 years, 54% boy). Bullying involvement, self-
Perpetration
harm behavior, anxiety, depression, and psychosocial difficulties were assessed by self-report questionnaire.
Mental health
Self-harm The prevalence of traditional school bullying and cyberbullying victimization was 33% (95% CI 32.1-34.5%) and
17% (95% CI 16.3-18.2%), respectively. The prevalence of traditional school bullying and cyberbullying
perpetration was 22.4% (95% CI 21.3-23.4%) and 10.4% (95% CI 9.7-11.3%), respectively. Bullying involve­
ment –as a victim, perpetrator, or both- was associated with anxiety, depression, psychosocial difficulties, and
self-harm behavior. Girls were more likely to be affected than boys in mental health outcomes. A significant
association between bullying victimization and negative mental health outcomes were also observed. These
findings provide evidence to intervention strategies need to target both traditional and cyberbullying involve­
ment. Understanding the risk profile will help create useful and appropriate interventions, which will reduce the
early effect of bullying on mental health and modify the clinical course.

1. Introduction 2014). The individuals may be involved by way of being a victim,

Bullying is defined as intentionally aggressive behavior that is re­
petitive and involves an observed or perceived power imbalance be­
tween victim and perpetrator (Gladden et al., 2014; Olweus & Limber,
2010). Researchers have differentiated two distinct forms: traditional
bullying and cyberbullying victimization (Chu et al., 2019). Traditional
bullying typically occurs face to face and may involve physical acts,
verbal taunting, ridicule, social exclusion, relational aggression, or other
behaviors (Wolke et al., 2000). In addition to traditional bullying,
cyberbullying becomes visible as a relatively new form of bullying
victimization involving aggressive behavior through electronic or digital
media by individuals or groups (Kowalski et al., 2014; Tokunaga, 2010).
It sometimes differs from traditional forms of bullying in that the per­
petrators remain anonymous (Ybarra & Mitchell, 2004), which may
result in more increased psychological stress and provides to perpetra­
tors the benefit of lack of face-to-face contact (Sampasa-Kanyinga et al.,
perpetrator, or victim-perpetrator.
Traditional school bullying, which has potentially serious conse­
quences for victims and families, is an old and persisting phenomenon. It
has been defined as any aggressive behavior that comprises intention to
harm, repetition, and power imbalance between victim and perpetrator
in school settings (Gladden et al., 2014; Salmon et al., 2018). More
recently, a great amount of attention has been paid to cyberbullying.
Both forms of bullying is a significant problem worldwide and have
negative consequences for individuals involved. Although the growing
worldwide initiatives to decline bullying by prevention programs,
particularly in school properties (Ttofi & Farrington, 2011), we are
currently far away from completely eradicated bullying victimization
(Garnefski & Kraaij, 2014). The prevalence of bullying involvement
varies considerably, and studies report that approximately 10-30 % of
adolescents are involved as bullies, victims, or both (Smith et al., 2002).
These varied results may be influenced by factors such as the definition

* Corresponding author at: Department of Child and Adolescent Psychiatry, Osmangazi University Faculty of Medicine, 26480, Eskisehir, Turkey.
E-mail address: meyuboglu@ogu.edu.tr (M. Eyuboglu).

https://doi.org/10.1016/j.psychres.2021.113730
Received 16 June 2020; Accepted 14 January 2021
Available online 16 January 2021
0165-1781/© 2021 Elsevier B.V. All rights reserved.
M. Eyuboglu et al.
of bullying, sample size, reference time interval, and how it is measured
(Salmon et al., 2018). A recent, large-scale study that conducted among
adolescent revealed that 15.9% of adolescents reported having been a
victim of bullying (Craig et al., 2009). Another meta-analysis of 80
studies which considered different bullying subtypes, showed that the
prevalence of traditional bullying and cyberbullying in adolescent is
36% and 15%, respectively (Modecki et al., 2014). While traditional
bullying and cyberbullying occour together, traditional bullying is twice
as common (Modecki et al., 2014). Although, it has been reported that
cyberbullying is infrequently experienced alone (Waasdorp & Brad­
shaw, 2015), studies have suggested unique nature of cyberbullying as
well (Antoniadou & Kokkinos, 2015; Kowalski et al., 2014). Further­
more, studies have shown that bullying-related behaviors may differ
across cultures (Kanetsuna et al., 2006). Prior researches reported that
bullying victimization might be greater in rural areas (Bradshaw et al.,
2009; Klein & Cornell, 2010). However, there is some evidence that
indicates the association between bullying and location. It is still unclear
that bullying experiences differ by location (Salmon et al., 2018). There
is also no consensus on genders related to being a victim of bullying.
Some studies showed that boys are more likely to be victimized than
girls (Bouffard & Koeppel, 2017; Cook et al., 2010), and other studies
suggested opposed findings (Boel-Studt & Renner, 2013; Merrill &
Hanson, 2016). However, it is commonly suggested that boys are more
likely to experience the physical type of bullying (Boel-Studt & Renner,
2013), whereas girls are more likely to encounter psychological or
relational victimization (Boel-Studt & Renner, 2013). Moreover, studies
showed that traditional bullying victimization is lower in older school
grades (Merrill & Hanson, 2016; Napoletano et al., 2016), but the as­
sociation between cyberbullying and school grade comprise some
inconsistent findings (Merrill & Hanson, 2016; Napoletano et al., 2016;
Tokunaga, 2010). It has been reported in various studies that a sub­
stantially high prevalence of bullying involvement in middle school
students, particularly in grades 6 through 8 (Nansel et al., 2001).
Nevertheless, less is known about gender differences and school grades
on all forms of bullying involvement and need to carry out with more
longitudinal studies.
Bullying and cyberbullying are widely recognized as major psycho­
social problems with substantial negative consequences. Over the last
decade, there has been increased attention to the association between
bullying involvement and mental health problems. Besides the impact
on the daily functionality of children who have been exposed to
bullying, the significant association with a range of mental health
problems has been described. Children who experienced bullying
victimization are at increased risk for various psychosocial conse­
quences, including academic struggle, low self-esteem, anxiety, and
depression (Roberts & Coursol, 1996; Srabstein & Leventhal, 2010).
Bullying has also been found to be associated with attention deficit and
hyperactivity disorder (ADHD) (Holmberg & Hjern, 2008). Studies also
report the associations between bullying, self-harm behavior, and sui­
cide among children and adolescents (Brunstein Klomek et al., 2007;
Brunstein Klomek et al., 2010). Further, victims of bullying are at an
increased risk for social outcomes such as deficit in social competence,
feeling of powerlessness, and peer rejection (Kvarme et al., 2010;
Nation et al., 2008). It has also been shown that bullying victimization is
independently associated with higher psychological distress and
decreased emotional wellbeing (Thomas et al., 2016). Moreover,
increasing evidence suggests that bullying victimization during child­
hood influences short-term and long-term wellbeing, extending
mid-twenties (Copeland et al., 2013). The existing literature indicates
that extended exposure to bullying victimization is also associated with
increased mental health problems (Boulton et al., 2010; Evans et al.,
2014). It means that there is a dose-response relationship between
bullying and mental health. It is also important to note that both victims
and perpetrators can experience these psychosocial consequences.
Another important point that needs further investigation is perpe­
trators/victims, defined as those who are bullied and bully others.
2
Psychiatry Research 297 (2021) 113730
Compared with pure victims and perpetrators, some authors reported
that perpetrators/victims have a higher risk for externalizing problems,
psychological symptoms, school, and interpersonal dysfunction (Fekkes
et al., 2004; Kokkinos & Panayiotou, 2004; Sourander et al., 2007).
However, there are some studies that showed no differences between
perpetrator-victim and pure victims or pure perpetrators (Liang et al.,
2007). Longitudinal studies still needed to examine associations be­
tween bullying and mental health in a large sample with victims and
perpetrators.
In Turkey, bullying is a relatively new phenomenon that attracts
increased attention from researchers. Studies showed that prevalence
rates of bullying have ranged from 22% to 91 % in Turkish adolescents
(Alikasifoglu et al., 2007; Arslan et al., 2012; Tural Hesapcioglu &
Ercan, 2017). Some researchers have also revealed the associations be­
tween bullying and mental health problems (Arslan et al., 2012; Tural
Hesapcioglu & Ercan, 2017). However, to date, no research, such a large
sample size has investigated the bullying, mental health problems, and
associated factors in Turkish children and adolescents. It is clear that
bullying is one of the most critical public health issues across the life­
span, and effective interventions should be aimed to reduce or stop
bullying, especially on the school property. Unfortunately, despite the
high prevalence of bullying and showing that it is one of the most
modifiable risk factors for mental health (Scott et al., 2014), there is no
enough effort to prevent it. Therefore, it is essential to note that finding
effective strategies is highly important to help us struggle with bullying
and prevent short and long-term negative psychological outcomes
(Garnefski & Kraaij, 2014). Additionally, from an intervention point of
view, increasing mental health professionals, educators, and parents’
awareness about mental health problems in children involved in
bullying is crucial.
As indicated, there is a lack of research on the prevalence and
mentioned mental health problems in relation to bullying in a large
sample in Turkey. Evidence concerning the relationship between
bullying and mental health and self-harm behavior is mostly from in­
ternational studies. Therefore in this paper, we conducted a study with
the largest sample size in Turkey to estimate the 12-month prevalence of
bullying and a reciprocal relationship between bullying and mental
health problems and self-harm behavior. This study aimed to determine
the prevalence of traditional and cyberbullying in a large sample of
middle-high school students. Moreover, we examined the association of
traditional school bullying and cyberbullying involvement experiences
with various mental problems such as self-esteem, psychosocial diffi­
culties, depression/anxiety, and self-harm behavior. We also examined
the involvement in bullying and psychological outcomes by gender and
school level.
With this objective and based on the analysis of previous studies, our
hypotheses were (1) traditional school bullying and cyberbullying
involvement would be significantly associated with low self-esteem,
higher levels of anxiety/depression, externalizing/internalizing prob­
lems, and self-harm behavior; (2) boys are more likely being perpetra­
tors than girls; (3) association between bullying victimization and
psychosocial problems would be stronger in girls; (4) while the preva­
lence of traditional bullying would decrease by school grade, cyber­
bullying would not display the same course; (5) dose-response
relationship would exist between bullying victimization and the mental
health problems, suggesting that adolescents who involve bullying are
more likely to have negative consequences of bullying.
2. Methods
2.1. Participants and procedure
The study was a cross-sectional school-based conducted in the
Eskisehir province located in the central Anatolia region of Turkey be­
tween October 2019 and December 2019. The sample of the current
study consisted of 6202 middle and high school students (46% girl, 54%
M. Eyuboglu et al.
boy). Participants’ age ranges from 11 to 18 years, with an average age
of 14.4 (SD=1.9). School grade distribution was 11.2% in Grade 6,
10.9% in Grade 7, 12.3% in Grade 8, 17.8% in Grade 9, 20.2% in
Grade10, 16.1% in Grade 11, and 11.5% in Grade 12. Surveys were
administered to students in nine middle and eight high schools. In order
to obtain a nationally representative sample of students, the schools
were selected randomly by a multistage stratified sampling method. The
middle and high schools selected from Eskisehir province, which is
categorized by socioeconomic status as low, average, and high. Then, we
used a simple random sampling method to choose the schools. All stu­
dents from the selected schools were invited to participate in the study.
Participation in the study was anonymous and voluntary. Completing
the self-report questionnaires took place at schools in a single class
period and took approximately 15 minutes. There is no information on
the number of students that declined to participate or the reason for
nonparticipation to the study.
The study was approved by the Eskisehir Osmangazi University
Ethics Committee and Eskisehir Provincial Directorate of National Ed­
ucation. Informed consent was obtained from all individual participants
and their parents included in the study.
2.2. Measures
2.2.1. Bullying
A 33-item self-report questionnaire adapted from previous studies
(CDC, 2004; Bauman et al., 2013; Merrill & Hanson, 2016) was modified
by the authors and used to assess bullying, self-harm behavior, and
sociodemographic data. Three categories of bullying were assessed:
perpetration, victimization, and both (victimization and perpetration).
Students were asking about traditional school bullying and cyberbully­
ing victimization and perpetration in the past 12 months. After the
definition of bullying was introduced on the instrument, school bullying
and cyberbullying were measured by the four following questions: (1)
During the past 12 months, have you ever been bullied on the school prop­
erty?; (2) During the past 12 months, have you ever bullied someone on the
school property?; (3) During the past 12 months, have you ever experienced
cyberbullying (by Instagram, Facebook, text messaging, etc.)?; (4) During the
past 12 months, have you ever cyberbullied (by Instagram, Facebook, text
messaging, etc.) someone?
The answer for each item was “never,” “few times,” “at least once a
month,” “at least once a week,” “almost every day.” We classified stu­
dents into the following groups: no bullying involvement (never
victimized and perpetrated), involvement in bullying (victimized and/or
perpetrated a few times or more during the last 12 months).
2.2.2. Self-harm behavior
One question concerning self-harm behavior was included in the
questionnaire. Participants were asked whether they had intentionally
hurt themselves (such as cutting, burning oneself) during the past 12
months?. The answer was “yes” or “no.”
2.2.3. Mental Health Problems
The Hospital Anxiety Depression Scale (HADS), which includes 14 self-
report items, was used to assess depression and anxiety symptoms. Even
the scale developed to assess mood symptoms in hospital settings, it is a
suitable instrument to be used in community and school properties
(Chan et al., 2010). The responses are on a four-point Likert-type scale
(0-3). The cutoff score was found to be 10 for anxiety and 7 for
depression (Aydemiret al., 1997). The Turkish version of the scale is
consistent and reliable. In the Turkish version of the scale, Cronbach’s
alpha value was 0.81 and 0.79 for anxiety and depression subscales,
respectively (Erkan, 2014).
Strength and Difficulties Questionnaire (SDQ) was used to screen
emotional and behavioral problems (Goodman et al., 1998). It includes
the 25 items rated on a three-point scale “ Not true” (0), “Somewhat
true” (1), or “Certainly true” (2). The scale consists of five subscales:
3
Psychiatry Research 297 (2021) 113730
behavioral problems, attention-deficit/hyperactivity, emotional prob­
lems, peer problems, and prosocial behavior. Total difficulties score
ranging from 0 to 40 and higher scores except prosocial behavior indi­
cate severe difficulties. The Turkish adaptation of the scale was per­
formed, and Cronbach’s alpha value was determined as 0.84-0.22 range
(Guvenir et al., 2008).
Rosenberg Self-Esteem Scale (RSES) was used to assess self-esteem.
The scale was developed by Rosenberg in order to measure self-esteem
especially in adolescents (Rosenberg, 1965). It consists of 10-items
self-report Likert-type and a total score ranging from 0 to 30. Higher
scores indicate a higher level of self-esteem. Scores between 15-25 are
within the normal range; scores below 15 suggest low self-esteem. The
scale is widely used among Turkish adolescents. The validity and reli­
ability coefficients of the Turkish version were found to be 0.71 and
0.75, respectively (Cuhadaroglu, 1986).
2.3. Data analysis
The Statistical Package for Social Sciences (IBM Corporation,
Armonk, NY, USA) version 23 was used to analyze the data. Pearson’s
Chi-square test and Fisher’s exact test were used in the comparison of
categorical variables. According to the distribution of variables, the
Student’s t-test or Mann-Whitey U test was used to analyze continuous
variables. The means, standard deviations, and number (%) are pro­
vided. Prevalence of bullying victimization, perpetration, and victim-
perpetration according to reported involvement that occurred “a few
times” or more often in the past year were calculated along with 95%
confidence intervals for each bullying experience type. If a respondent
had experienced bullying behaviors as a victim, perpetrator, or both, he
or she was defined as a bullying victim, bullying perpetrator, or victim/
perpetrator. As a result, we differentiated the students into four cate­
gories: pure victims, pure perpetrator, victim-perpetrator, and students
who had never experienced bullying as a victim or perpetrator based on
their self-reported bullying experiences (comparison group). Second,
one-way ANOVA (Post hoc Tukey analysis in multiple group compari­
son) was used to compare mental health problems such as depression,
anxiety, and self-esteem between groups. Besides, we tested whether
there were gender differences in mental health problems and self-harm
behavior between victims, perpetrators, and victim/perpetrators.
Bivariate associations between each type of bullying and mental health
problems were estimated. Multiple regression analyses were conducted
to estimates the association between bullying and SDQ, depression,
anxiety, and self-harm behavior. In the regression models, only variables
that were significant in correlations were entered into the regression
models. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were
estimated. The value of statistical significance was determined as p <
0.05.
3. Results
3.1. Sample Characteristics and prevalence of bullying involvement
Out of the 6202 cases, 46.1% (n=2859) were female and 53.1%
(n=3343) were male. The Male: Female ratio of our sample was similar
to the general Turkish population (TSI, 2019). The respondents were
11-18 years old, with the mean age was 14.4 ±1.9 years. Participants’
school grades ranged from 6th to 12th. Prevalence rates of various
bullying experiences and self-harm behavior of the sample overall and
by genders in the past one year are shown in Table 1. Overall, the
prevalence of bullying and cyberbullying victimization was 33% (95%
confidence interval [CI] = 32.1-34.5%) and 17% (95% confidence in­
terval [CI] = 16.3-18.2%), respectively. A total of 22.4% (95% confi­
dence interval [CI] = 21.3-23.4%) of respondents reported being
perpetrators of traditional school bullying, whereas 10.4% (95% confi­
dence interval [CI] = 9.7-11.3%) reported being perpetrators of cyber­
bullying. Regarding the types of bullying involvement, 57.0% (n=3538)
M. Eyuboglu et al. Psychiatry Research 297 (2021) 113730

Table 1 and grade 12 (χ2=48.28, df=6, p<0.001), respectively (Figure 1). Be­
Prevalence of bullying victimization, perpetration and victim-perpetration in sides, while school bullying perpetrators were mostly in 8th grade
the sample by gender. (χ2=64.51, df=6, p<0.001), cyberbullying perpetrators were mostly in
Total boys girls 95% CI 12th grade (χ2=44.93, df=6, p<0.001) (Figure 2). These data support
sample % our hypothesis that grade differences occur in traditional bullying and
N (%) N (%) N (%) Lower- cyberbullying. The prevalence of traditional bullying victimization de­
Higher
creases from grade 8. There was a significant negative correlation be­
Traditional Pure victims 1278 616 662 19.6- tween traditional bullying victimization and school grade (r=-.22,
school bullying Pure (20.6) (18.4) (23.2) 21.6
p<0.001) in children involving traditional school bullying, but no cor­
perpetrator 601 421 180 9.0-10.5
Victim/ (9.7) (12.6) (6.3) 11.8- relation was found between being perpetrators and school grade. In
perpetrator 785 494 291 13.5 addition, there was a significant relationship between bullying victim­
No (12.7) (14.8) (10.2) 55.8- ization (r=.08, p<0.001), perpetration (r= .07, p<0.001), and school
involvement 3538 1812 1726 58.3 grade in children involving cyberbullying. These results also show that
(57.0) (54.2) (60.4)
Cyberbullying Pure victims 730 310 420 11.1-
while traditional school bullying victimization decreased by school
Pure (11.8) (9.3) (14.7) 12.6 grades, cyberbullying did not exhibit a similar pattern across school
perpetrator 312 220 92 4.5-5.6 grades.
Victim/ (5.0) (6.6) (3.2) 4.9-6.0
perpetrator 337 219 118 76.7-
No (5.4) (6.6) (4.1) 78.8 3.2. Self-harm behavior
involvement 4823 2594 2229
(77.8) (77.6) (78.0) The prevalence of self-harm behavior was 7.5% in the whole sample.
CI: confidence interval. Among the traditional school bullying, the rate for self-harm behavior
for pure victims, pure perpetrators, and victim-perpetrators was 8.1%,
of participants reported that they had never been involved in traditional 14.1%, and 15.2%, respectively, compared to 4% of uninvolved chil­
school bullying, and 77.8% (n=4823) of them reported that they had dren. Among children involving cyberbullying, the rate for self-harm
never been involved in cyberbullying. behavior for pure victims, pure perpetrators, and victim and perpetra­
Chi-squared analyses were conducted to examine gender differences tors were 11.4%, 15.7%, and 20.5%, respectively. Bullying involvement
between groups. As hypothesized, bullying involvement differentially (victim, perpetrator or both) was with significantly increased risk for
affected boys and girls. Among the children who involved in traditional self-harm behaviour in school bullying (4% vs 11.6%, chi-square test,
school bullying, although no significant gender differences were found χ2=113.4, df=1, p < 0.001) and cyberbullying (4% vs 14.6%, chi-square
on bullying victimization (χ2=0.12, df=1, p=0.914), boys were signif­ test, χ2=129.7, df=1, p < 0.001). No significant gender difference was
icantly more likely to report being pure perpetrator (12.6% vs. 6.3%, observed in children who experienced traditional bullying (11.8% vs
χ2=105.43, df=1, p<0.001), and victim/perpetrator (14.8% vs. 10.2%, 11.4%, chi-square test, χ2=0.13, df=1, p=0.71) and cyberbullying
χ2=115.81, df=3, p<0.001) than girls. Among the children involved in (15.1% vs 14.2%, chi-square test, χ2=0.23, df=1, p=0.62).
cyberbullying, girls were significantly more likely to be victims than
boys (18.8% vs. 15.8%, χ2=9.69, df=1, p=0.002). However, boys were 3.3. Bullying involvement and mental health problems
more likely to be a perpetrator (13.1% vs. 7.3%, χ2=50.07, df=1,
p<0.001) and victim-perpetrators (6.6% vs. 4.1%, χ2=89.75, df=3, Results for the nine mental health outcomes are listed in Table 2. We
p<0.001) than girls. Table 1 shows the percentages of bullying by found negative mental health consequences in children who have been
gender. involved in traditional school bullying and cyberbullying (i.e., victim,
In terms of school grades, traditional school bullying and cyberbul­ perpetrator, or victim-perpetrator) than non-involved students. The re­
lying victimization were mostly at grade 8 (χ2=154.18, df=6, p<0.001) sults indicated that depression, anxiety, self-esteem, and psychosocial

Fig. 1. Prevelance of school bullying and cyberbullying victimization by grade.

4
M. Eyuboglu et al.
Fig. 2. Prevelance of school bullying and cyberbullying perpetration by grade.
difficulties of participants who have been involved in traditional school
bullying and cyberbullying were significantly worse (Table 2). Partici­
pants involving bullying also showed more externalizing and internal­
izing symptoms than their non-involved peers. Tukey post hoc analyses
showed that the victim-perpetrator of traditional school bullying
showed the highest SDQ total score. Besides, pure perpetrators showed
the highest score for conduct problems in both groups.
With regard to gender differences in students involving traditional
school bullying: girls reported significantly more symptoms of anxiety
(student’s t-test, t=10.43, p<0.001), SDQ total scores (student’s t-test,
t=4.47, p<0.001), and showed lower self-esteem (student’s t-test, t=-
8.64, p<0.001), than boys. There was no significant difference in
depression (student’s t-test, t=1.85 p=0.064).
With regard to gender differences in students involving cyberbully­
ing: girls reported significantly more symptoms of anxiety (student’s t-
test, t=9.88, p<0.001), depression (student’s t-test, t=20.38, p=0.042),
SDQ total scores (student’s t-test, t=4.49, p<0.001), and showed lower
self-esteem (student’s t-test, t=-6.32, p<0.001) than boys. These results
support our hypothesis that mentioned girls would be affected more
than boys in mental health problems.
3.4. Associations between bullying victimization and mental health
problems and self-harm behavior
The results of examining the association between bullying involve­
ment and various mental health problems are shown in Table 3. Pearson
correlation coefficients were calculated to examine relationships among
bullying involvement and mental health problems. The results indicated
significant associations between the involvement of both forms of
bullying and mental health problems and self-harm behavior (Table 3).
The involvement in bullying was significantly associated with higher
levels of depression/anxiety, lower self-esteem, and higher self-harm
frequency in affected children. Moreover, there was a significant inter­
action between being involved in school bullying and cyberbullying.
To test our hypothesis that suggests a dose-response relationship
would exist between bullying victimization and mental health problems,
we examined the cumulative effect of bullying on measured variables.
Associations between bullying victimization frequency (“never,” “few
times,” “at least once a month,” “at least once a week,” “almost every
day” during the last year) and mental health problems were calculated.
We found a dose-response relationship between bullying victimization
5
Psychiatry Research 297 (2021) 113730
consequences of school bullying
and negative mental health outcomes in support of our hypothesis.
Cumulative school bullying victimization was significantly associated
with depression (r=.15, p<.001), anxiety (r=.21, p<.001), self-esteem
(r=-.19, p<.001), psychosocial difficulties (r=.25, p<.001), and self-
harm behavior (r=.14, p<.001). Cumulative cyberbullying victimiza­
tion was also significantly associated with depression (r=.16, p<.001),
anxiety (r=.19, p<.001), self-esteem (r=-.14, p<.001), psychosocial
difficulties (r=.18, p<.001), and self-harm behavior (r=.12, p<.001).
Binary logistic regression analyses were performed to understand the
relationship between assessed variables such as anxiety, depression, self-
esteem, and self-harm behavior with each of the bullying involvement.
Students involving bullying, regardless of being victim, perpetrator, or
both, were selected into the involved group (0; no involvement, 1;
involved). Prevalence of involving in traditional school bullying and
cyberbullying was 43% and 22.2%, respectively. We performed a
regression model for each type of bullying separately. In the regression
models, being involved in school bullying or cyberbullying in the last 12
months was added as a dependent variable. Self-harm behavior (0; none,
1; yes), depression, anxiety, self-esteem, and psychosocial difficulties
obtained from SDQ, were added as independent variables. Variables
were added to the models as categorical or numerical data. Stepwise
regression analyses were performed, and interaction effects were
computed for each type of bullying and assessed variables.
As a result of the analysis, in the final model, it was determined that
involved traditional school bullying had a significant association with
depression, anxiety, psychosocial difficulties, and lower self-esteem
(Table 4). A similar result was found in the final model of involve­
ment in cyberbullying (Table 4).
With regard to self-harm, involvement in bullying was associated
with an increased risk of self-harm behavior (traditional bullying: OR
1.96, p<0.001 95% CI 1.5-2.4; cyberbullying: OR 1.99, p<0.001 95% CI
1.6-2.5). Moreover, multinominal logistic regression analyses were
conducted to find out the highest risk group. Compared with the stu­
dents who have not been involved, the results indicated that among
children who involving traditional school bullying, pure perpetrators
showed the highest risk for self-harm behavior (pure victim: OR 1.4,
p<0.001 95% CI 1.1-1.8; pure perpetrator: OR 2.5 p<0.001 95% CI 1.9-
3.4; victim-perpetrator: OR 2.4, p<0.001 95% CI 1.8-3.2). Among the
children who involved cyberbullying, victim-perpetrators showed
highest risk for self-harm behavior (pure victim: OR 1.5, p<0.001 95%
CI 1.2-2.0; pure perpetrator: OR 2.1, p<0.001 95% CI 1.5-3.0; victim-
 Table 2
Bullying and mental health problems.
M. Eyuboglu et al.

Traditional school bullying Cyberbullying

No involvement Pure victim Pure perpetrator Victim- No involvement Pure victim Pure perpetrator Victim-
(NI) (PV) (PP) perpetrator (VP) (NI) (PV) (PP) perpetrator (VP)

Mean(SD) Mean(SD) Mean(SD) Mean(SD) p Post Hoc Mean(SD) Mean(SD) Mean(SD) Mean(SD) p Post Hoc
Self esteem 20.6 (5.6) 18.6 (5.6) 19.9 (5.5) 18.0 (5.8) <0.001 NI>PP>PV=VP 20.2 (5.5 17.7 (5.9 19.1 (6.4 18.3 (5.8 <0.001 NI>PP=VP>PV
Anxiety 8.2 (4.4) 10.2 (4.5) 9.3 (4.2) 10.7 (4.3) <0.001 VP=PV>PP>NI 8.6 (4.3 11.2 (4.5 9.6 (4.4 10.8 (4.5 <0.001 PV=VP>PP>NI
Depression 5.8 (3.7) 6.8 (3.9) 6.9 (3.9) 7.2 (3.8) <0.001 PV=PP=VP>NI 5.9 (3.7 7.5 (4.1 7.4 (4.0 7.5 (3.9 <0.001 PV=VP=PP>NI
SDQ-emotional 2.9 (2.2) 3.9 (2.5) 3.1 (2.2) 3.9(2.4) <0.001 VP=PV>PP>NI 3.0 (2.3) 4.2 (2.5) 3.5 (2.4) 3.9 (2.5) <0.001 PV=VP>PP>NI
score
SDQ- conduct 2.4 (1.7) 2.7 (1.7) 3.7 (1.9) 3.5 (1.8) <0.001 PP>VP>PV>NI 2.5 (1.7) 3.0 (1.6) 4.0 (1.9) 3.7 (2.0) <0.001 PP>VP>PV>NI
problems
SDQ-ADHD score 4.1 (2.0) 4.5 (2.1) 4.8 (2.0) 5.0 (2.0) <0.001 VP=PP>PV>NI 4.2 (2.0) 4.7 (2.0) 4.9 (2.1) 5.1 (2.1) <0.001 VP=PP>PV>NI
SDQ-Peer 2.5 (1.7) 3.2 (1.9) 2.9 (1.8) 3.4 (1.9) <0.001 VP=PV>PP>NI 2.7 (1.8) 3.3 (1.9) 3.1 (1.9) 3.3 (1.8) <0.001 VP=PV=PP>NI
problems
SDQ-prosocial 7.9 (2.0) 8.0 (2.0) 6.7 (2.3) 7.1 (2.2) <0.001 PV=NI>VP>PP 7.8 (2.0) 7.8 (2.1) 6.3 (2.5) 6.6 (2.4) <0.001 NI=PV>VP=PP
behaviour
SDQ total 11.8 (5.2) 14.3 (5.6 14.6 (5.2 15.8 (5.4 <0.001 VP> 12.4 (5.4 15.2 (5.3 15.5 (5.3 16.0 (5.6 <0.001 VP=PP=PV>NI
PP=PV>NI

One way ANOVA, SDQ: Strength and Difficulties Questionnaire.

6
Table 3
The association of bullying involvement and mental health problems and self-harm behaviour.
TSB CB Sel- Self- Anxiety Depression SDQ-Emotional SDQ- conduct SDQ- ADHD SDQ-Peer SDQ Prosocial SDQ
involvement involvement harm esteem score problems score problems behavior total

TSB involvement 1
CB involvement .32** 1
Sel-harm .14** .15** 1
Self-esteem -.16** .14** -.15** 1
Anxiety .21** .19** .13** -.48** 1
Depression .15** .16** .14** -.53** .51** 1
SDQ-Emotional score .18** .17** .14** -.47** .60** .41** 1
SDQ- conduct .22** .20** .15** -.19** .28** .28** .28** 1
problems
SDQ- ADHD score .16** .13** .10** -.31** .33** .27** .36** .31** 1
SDQ-Peer problems .18** .13** .15** -.29 .26** .34** .34** .28** .16** 1
SDQ Prosocial -.12** -.12** -.10** .14** -.06** -.26** -.08** -.35** -.19** -.23** 1
behaviour
SDQ total .27** .23** .19** -.47** .57** .48** .77** .64** .68** .61** -.29** 1
**
p<0.001, TSB: Traditional school bullying, CB: Cyberbullying, SDQ: Strength and Difficulties Questionnaire
Psychiatry Research 297 (2021) 113730
M. Eyuboglu et al. Psychiatry Research 297 (2021) 113730

Table 4 perpetrators than girls in both forms of bullying. This finding is also
The risk of depression, anxiety, self-harm, self-esteem, and psychosocial diffi­ consistent with previous studies (Chu et al., 2019). Several reasons could
culties in different types of bullying involvement. explain these result; (ı) externalizing problems occurs more in boys than
Traditional school bullying Cyberbullying involvement girls, (ıı) boys are more prone to display aggressive behavior and
involvement violence and (ııı) this may result of providing a prominent social place in
OR CI (95%) p OR CI (95%) p a group or peer relations (Carrera Fernández et al., 2013; Silva et al.,
lower- lower- 2013). We also showed that children involved in bullying might be in
upper upper different roles, as shown that boys are more prone to be victim and
Depression 0.98 0.96-0.99 0.013 0.87 0.75-0.99 0.045 victim-perpetrator.
Anxiety 1.06 1.04-1.08 <0.001 0.75 0.64-0.86 0.001 Grade differences indicated that while school bullying decreased
Self-harm 1.96 1.56-2.41 <0.001 1.99 1.62-2.45 0.001 with the grade, there was no decreasing cyberbullying victimization
Self-esteem 0.98 0.97-0.99 0.003 0.84 0.71-0.99 0.037
SDQ- 1.01 098-1.03 0.78 1.06 1.03-1.09 0.001
trend. A similar pattern was found in bullying perpetration. These
Emotional findings are supported by previous studies (Merrill & Hanson, 2016;
score Napoletano et al., 2016; Tokunaga, 2010). Our findings suggest that
SDQ- 1.14 1.10-1.18 <0.001 1.16 1.11-1.19 0.001 traditional school bullying victimization peak at the end of middle
Conduct
school, but decline later. This may result from victims’ physical, social,
problems
SDQ-ADHD 1.06 1.02-1.09 <0.001 1.04 1.01-1.07 0.04 and emotional growth as they get older that results in decreasing per­
score petrators around them and/or having better skills to protect themselves.
SDQ- Peer 1.12 1.08-1.15 <0.001 1.02 0.98-1.05 0.25 They may also become to making bullying less effective. Besides, the
problems increasing use of cell phones and the internet by age may have turned
SDQ- 0.97 0.94-1.00 0.058 0.94 0.91-0.97 0.001
prosocial
the form of bullying from the traditional way to the online form. This
score pattern may explain a fairly constant level of cyberbullying and should
be understood as an alarm. On the other hand, younger children were
Logistic regression analyses, OR: Odds ratio, CI: Confidence interval, SDQ:
more likely to be involved in traditional school bullying may show the
Strength and Difficulties Questionnaire.
low awareness of teachers and parents, particularly in middle
school-aged children.
perpetrator: OR 2.9, p<0.001 95% CI 2.1-4.0).
As hypothesized, compared to uninvolved peers, traditional bullying
and cyberbullying involvement was associated with much worse mental
4. Discussion
health and elevated risk of self-harm behavior. This significance
remained after the regression model, and the risk was similar in 3 forms
This regional school-based study provides supporting evidence for
of bullying involvement. Our observation that bullying victimization is
the associations between bullying and psychosocial difficulties,
associated with mental health problems is confirmed by several studies
emotional problems, self-esteem, and self-harm behavior in Turkish
(Menrath et al., 2015; Srabstein & Leventhal, 2010). The finding from
middle and high school students. The present study also contributes to
the current study shows that bullying involvement may be a factor for
our understanding of bullying and cyberbullying by examining both the
poor mental health and self-harm. Moreover, our findings confirm a
prevalence and gender and school grade differences using a large
dose-response relationship between bullying victimization and
population-based sample. Results showed that traditional school
measured variables, which means that a higher frequency of victimiza­
bullying involvement is considerably prevalent in the educational stage,
tion results in decreased mental health outcomes and higher self-harm
and cyberbullying also largely occurs within this population. Moreover,
behavior. This finding supports the previous researches showing that
we demonstrate that involvement in bullying – as a victim, perpetrator,
prolonged bullying victimization might have long-term destructive
or both- is associated with depression, anxiety, externalizing/internal­
consequences (Evans et al., 2014; Rusby et al., 2005). In regard to
izing problems, and self-harm behavior. These findings pertained to
gender differences, even significant associations between bullying
both males and females and were found across all mental health prob­
involvement and mental health were present both for boys and girls; the
lems; however, girls are more affected than boys.
relationship was stronger for girls, particularly in cyberbullying. Previ­
The prevalence of traditional school bullying victimization and
ous studies suggested that females are particularly vulnerable to expe­
perpetration was 33% and 22.4%, respectively. The prevalence of vic­
rience distress and depressive symptoms from early adolescence to
tims and perpetrators of cyberbullying was 17% and 10.4%, respec­
adulthood (Kessler et al., 1993) and more likely to ruminate when they
tively. Even the prevalence of bullying varies across countries, the
experienced relational stress (Mezulis et al., 2002). This is important
results documented in the current study are compatible with recently
because compared to boys, girls are more likely to be involved in rela­
reported studies (Boak et al., 2018; Schneider et al., 2012; Shetgiri et al.,
tional forms of bullying (Orpinas et al., 2015), and this form may be
2012). These considerable proportions support the need for further ac­
emotionally more harmful. Further, in line with previous researches,
tions and intervention against bullying and suggest that the bullying
Feinstein et al. reported that rumination mediated the association be­
phenomenon is not placed dependent. Previous studies have shown
tween cyberbullying and depressive symptoms in girls (Feinstein et al.,
different results regarding gender differences. In our study, even there
2014). Particularly when facing negative experiences, if they could not
were no differences in school bullying victimization, girls were more
use appropriate coping strategies, it may result in increased distress.
experienced cyberbullying victimization. The finding that showed no
Hereby, those may explain girls’ higher proportion of mental health
gender differences in traditional bullying victimization is inconsistent
problems when faced with bullying.
with much of the literature (Bouffard & Koeppel, 2017; Salmon et al.,
We compared the risk of various mental health problems among
2018). However, supporting our result, some studies showed that girls
different levels of bullying involvement. Our result seems to contrast
are more likely to be victimized in cyberbullying (Dehue et al., 2008;
with previous studies that showed victim-perpetrator had the highest
Smith et al., 2008). This may be because girls are mostly bullied on an
risk for mental health problems (Fekkes et al., 2004; Kokkinos & Pan­
emotional level (Boel-Studt & Renner, 2013). As we did not investigate
ayiotou, 2004; Sourander et al., 2007). However, the current study ex­
different bullying types, it remains unclear to explain gender differences
tends the literature by showing that perpetrators and
found in our study, but further studies should investigate different
victim-perpetrators are also associated with adverse psychological out­
bullying types and causal associations by gender. Another finding of our
comes similar to victims. Our findings are consistent with the previous
study regarding gender differences was, boys were more prone to be
studies, which have shown that perpetrators and victims are at risk of

7
M. Eyuboglu et al.
poor mental health, including depression and anxiety (Arseneault et al.,
2006; Turner et al., 2014). As we found that mental health problems are
associated with perpetration, the mechanism of this association is not
well understood. However, there may be a bi-directional relationship.
Children with mental health disorders, particularly externalizing dis­
order, may more likely to bully others, or children who experienced
bullying victimization may become perpetrators to protect themselves
or struggle with this disproportionate social environment. Besides
sadness, hopelessness, fear, and worry that mostly experienced related
to victimization, many studies showed the high rates of reactive
aggression displayed by victims (Camodeca & Goossens, 2005; Salmi­
valli & Nieminen, 2002). Further, there are some other factors that effect
to be perpetrator: expose the violence, inappropriate family structure,
and lack of parental support may be among those factors. Therefore,
further studies should investigate the nature of perpetration and clarify
the relationship between perpetration and mental health problems. Our
results suggest extending researches design from victimization to
involvement in bullying. It is also important to emphasize that if inter­
vention strategies focus on victims, this will impede those programs’
success by missing to reach all children who are involved in bullying and
have a high risk for poor mental health.
Our results indicate that bullying as a risk factor for engagement in
self-harm behavior, particularly perpetrators. Despite there are several
reasons that may result in self harm-behavior such as genetic risk and
environmental factors, internalizing and externalizing problems that
have also shown in our study may have a mediating role of self-harm as
previously described (Claes et al., 2015). However, the mechanism un­
derlying these associations is still unclear. Another hypothesis could be
that this behavior may be a part of help-seeking behavior when children
can not express their emotions or do not have an appropriate family
environment to express their difficulties. Due to the lack of evidence for
suicide in the current study, future researches should clarify the
distinction between self-harm behavior and intention to die. Neverthe­
less, it is commonly known that regardless of suicidal or non-suicidal
intention, children who engage with self-injury have a higher risk of
mental disorder and show similar demographic variables (Karanikola
et al., 2018).
This study is the largest population-based study in Turkey that
examined children’s various mental health problems involving tradi­
tional school bullying and cyberbullying. However, several limitations
need to be considered when interpreting the results of the current study.
First, our study’s cross-sectional design prevents us from drawing con­
clusions about the causal relationship between involvement in bullying
and mental health problems. Multi-wave longitudinal studies are needed
to understand the directionality of this relationship better. Second, the
data from our study gathered by self-report scales, which may be caused
some bias. There was also no data obtained from peers, parents, or
teachers. Third, while bullying experiences measured for the past year,
mental health problems mostly measure last month. Therefore, the effect
of bullying that have lasted before the last month might be missed.
Fourth, it is also important to note that participants reported their cur­
rent grade. Thus, it should be kept in mind that some children may
experience bullying involvement in the previous grade. Fifth, the sub­
types of traditional school bullying, such as physical, verbal, and rela­
tional, have not been distinguished.
5. Conclusion
In conclusion, our study has several important clinical and public
mental health implications within the context of these limitations. We
showed the prevalence of traditional school bullying and cyberbullying
victimization and/or perpetration in the Turkish sample. The prevalence
of bullying involvement varied according to gender and school grade.
The result of this study also indicates that children involved in bullying
either as the perpetrator, victim, or victim-perpetrator, have a larger risk
of mental health problems and self-harm behavior. Furthermore, based
8
Psychiatry Research 297 (2021) 113730
on our results, females carry a greater risk of poor mental health, and the
frequency of victimization is associated with depression, anxiety, self-
esteem, psychosocial difficulties, and self-harm behavior. These find­
ings provide evidence that intervention strategies need to target both
traditional and cyberbullying perpetration and victimization by
considering gender and school grades. Understanding the risk profile
will help to create useful and appropriate interventions. This will allow
to reduce the early effect of bullying on mental health and modify the
clinical course. Additionally, intervention programs should not pri­
marily focus on psychoeducation. Coping strategies to enhance mental
resiliency should be provided to students and professionals (Tiiri et al.,
2020). It is also important to encourage students to seek help and get
support by telling someone about bullying when they experienced it.
Finally, national school-based intervention programs need to integrate
and target both forms of bullying.
Authors’ contribution
Conceptualization, methodology, and writing – original draft, M.E.
and D.E., formal analysis, investigation, supervision, D.A., and A.U.,
data curation, methodology, S.C.P., D.O., and Z.D. All authors contrib­
uted to the interpretation of data and approved the final version.
Roles of funding source
This research did not receive any specific grant from funding
agencies in the public, commercial, or non-profit sectors.
Declaration of Competing Interest
No conflict of interest exists.
Acknowledgments
None
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.psychres.2021.113730.
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